Rathbone GroupRevised March 2023
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that “…every person…who claims damages from any municipality…shall cause to be presented to the governing body of the
municipality within 180 days after the alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation
or other relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation, you may add those
documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4)
weeks. This form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: ___ NA__ Last Name: ___NA____________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: Rathbone
Group_______________________________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? YES If yes, what is your File Number?
_______________3141709________________________
If yes, provide your Insured’s/ Client’s Name: __Kentucky Farm Bureau a subrogee of Evan
Brown_____________________________________________________________________
Street Address: _C/O Rathbone Group 1250 E. Granger Rd.
_____________________________________________________________________________________________
City: Cleveland State: Ohio Zip Code: 44131
Daytime/Work Phone: 8558694042 Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 1/4/2023 Time: ____________9:27 PM_________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _City police vehicle struck vehicle and also
caused injuries.___________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The officer is clearly at fault as proved by
the police report. Was unable to stop after sliding on ice into an intersection striking our client’s insured vehicle.
____________________________________
Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
☒ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two estimates for repairs or actual bill that has been paid.
Revised March 2023
☒ You were injured during a motor vehicle accident: please provide police report number, details about injury.
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
Is there a police report for this incident? YES
If yes, please provide the police report case number: __23-001640_________________________
If yes, what law enforcement agency responded? Saint Paul Police
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Dale Stree N and Concordia Ave in St. Paul
What would you like to see happen to resolve this claim to your satisfaction?
___________________________________________________________________ That our property and bodily injury subrogation
claims are paid in full. ___________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
Brett Auewmeland 313 Dale St. Paul , MN
________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2014______ Make: Nissan Model: Altima Color: Silver
License Plate #: 892PYJ State vehicle is registered in: KY
Registered owner of vehicle: Evan Brown Driver: Evan Brown
Area(s) damaged: left front door, left rear door, left quarter panel, wheelhouse, rocker molding
If a City vehicle was involved, License Plate #: _____________Unknown____________________ Color:
________________Black_______________
Was there City insignia on the vehicle? YES Driver’s Name: ________Andrew
Lewis______________________________________________
Other property damaged:
___________None____________________________________________________________________________
For injury claims of any type.
What part of your body was injured?
___unknown__________________________________________________________________________
Did you go to the emergency room or urgent care? YES Where? _______Regions
Hospital____________________________________________
Was medical treatment received? YES Where? ________Regions
Hospital________________________________________________________
First day of medical treatment? 1/4/2023 Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO
Employer(s):
______________________________________unknown___________________________________________________________
Revised March 2023
How much time have you missed from work?
_______unknown______________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: Salvage for the vehicle is
pending. Repair estimate and photos and med supports will be provided.
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form: _____Mark Gordon_of Rathbone Group on behalf of Kentucky Farm Bureau, subrogee of Evan
Brown_______________________________________________________
Signature of Person submitting this form: Mark Gordon
Relationship of person signing to Party making the claim: Attorney
Date document is being signed: 5/9/2023